Asthma is one of the most common chronic diseases affecting children. Surveys indicate that nearly five million American children under age 18 have experienced asthma symptoms. Many of those children begin developing asthma in very early childhood, before they turn five years of age.

This fact sheet provides detailed information about asthma in very young children — babies, toddlers, and preschool aged children. We hope that this material helps you better understand what asthma is, how to recognize it in a young child, and what to do about it. Please keep in mind that this information is not meant to take the place of medical advice from your own physician.

When Hunt and Alison had their third child, Kayla, they treated her periodic coughs and sniffles with the same common sense approach they’d used with their first two kids. But after 14-month-old Kayla ended up in the hospital emergency department, her lips a pale blue and her tiny chest grasping for every breath, they knew she had more than another “regular” cold. Reviewing her history with the pediatrician, they learned how to manage Kayla’s asthma symptoms and what to do to avoid future emergencies.

What is asthma?

Asthma is a disease characterized by chronic inflammation of the airways. This inflammation causes narrowing of the airways and an increased sensitivity to inhaled irritants and allergens. People with asthma are said to have hyperactive airways, meaning their respiratory tract overreacts to things that would just be minor irritants for people without asthma.

The root cause of asthma is still unknown; however, physicians do know that an increase in asthma symptoms often results from having a respiratory infection or when the sensitive person comes into contact with various allergens, engages in vigorous exercise, inhales cold air, or is exposed to air pollution. Allergens and irritants are substances found in our everyday environment.

Common symptoms of asthma include wheezing, cough, shortness of breath, and a feeling of chest tightness. Asthma can begin at any age. With proper management and education, people with asthma can lead normal, active lives.

How is asthma in very young children different from asthma in adults?

Infants and toddlers have much smaller airways than older children and adults. In fact, their airways are so small that even small amounts of swelling of the lining of the airways caused by viral infections, tightened airways, or increased amounts of mucus can block the flow of air making breathing extremely difficult for the infant or young child. The first episodes of asthma in young children are often triggered by viral respiratory infections. These young children cannot tell their parents that they are having trouble breathing. As a result, infants or young children with viral respiratory infections should be monitored for the signs and symptoms of asthma discussed below.

Which infants or young children are more likely to develop asthma?

Children are at a higher risk for wheezing in the first years of life if they are born prematurely; if their mother smoked during pregnancy; if they have a family history of asthma or allergies; or they have a personal history of eczema. Infants and children who wheeze once often wheeze again. Young children who have wheezed before should be carefully monitored for symptoms and signs of asthma when they have respiratory viral illnesses.

What are the signs of asthma in a baby or toddler?

Signs or symptoms of asthma in a very young child include:

• Noisy breathing

• Rate of breathing increased 50% or more above normal

(Look for other asthma symptoms such as those listed here in addition to the increase in respiratory rate)

Normal respiration rates

– Newborns: 30-60 breaths/minute

– 1st year: 20-40 breaths/minute

– 2nd year: 20-30 breaths/minute

• Wheezing or panting with normal activities

• Lethargy, disinterest in normal or even favorite activities

• Difficulty sucking or eating

• Crying sounds are softer or different

• Persistent cough

• Labored breathing

Asthma symptoms can quickly develop into a serious medical condition, especially in infants and toddlers. Parents may not be aware that asthma symptoms are becoming serious, possibly leading to a medical emergency. If your child demonstrates any of the symptoms listed below, seek medical treatment immediately!

• Breathing increased 50% or more above normal

• Difficulty with sucking or eating that leads to refusal to eat altogether

• Rapid movement of the nostrils or nostril flaring

• Ribs or stomach moving in and out deeply and rapidly

• Expanded chest that does not deflate when the child exhales

• Cyanosis — very pale or bluish coloring around the lips, the fingernail beds

• Failure to respond to or recognize parents

Do other illnesses or conditions have the same symptoms as asthma in very young children?

Yes. Newborns, infants, and toddlers can exhibit asthma-like symptoms of wheezing, coughing, and difficulty breathing with a number of different diseases, illnesses, or conditions. These include:

• Croup

• Epiglottitis

• Bronchitis

• Bronchiectasis

• Pneumonia

• Upper respiratory tract viruses

• Gastroesophageal reflux

• Aspiration of food or liquids when eating or drinking

• Inhaled foreign object

• Congenital abnormalities

Your pediatrician or an asthma specialist can assess your child to determine the underlying cause of the asthma- like symptoms. In any event, don’t ignore the symptoms, but seek treatment as soon as possible. Toddlers and preschool aged children often continue to be fairly active in spite of increasing chest tightness or difficulty breathing.

How is asthma diagnosed in babies and toddlers?

Diagnosing asthma in very young children is difficult. Since they are not able to communicate, they cannot describe how they are feeling. A baby’s fussy behavior could mean many things.

To help your pediatrician make a correct diagnosis, you must be able to provide information as follows:

• Any family history of asthma or allergies

• The child’s overall behavior

• Breathing patterns and breathing changes

• Responses to foods

• Possible asthma or allergy triggers you have observed

Pulmonary (lung) function tests are routinely used in older children and adults to help confirm an asthma diagnosis but these tests are very hard to do with young children. Instead, your physician may want to examine your child when your child has symptoms and may choose to observe how your child’s symptoms respond to asthma medications given to improve breathing. In addition, blood tests, allergy testing, and x-rays may be done to gather additional information.

Using all this data, your physician then can make the best diagnosis. Sometimes parents are referred to a pediatric allergist or pulmonologist (lung specialist) for specialized testing or treatment.

What is the treatment for asthma in very young children?

Babies and toddlers can take most asthma medications prescribed for older children and adults. The dosage, of course, is lower and the way the medication is given is different. In general, inhaled medications are preferred for asthma treatment because they act more rapidly to reduce symptoms and produce fewer side effects.

Medications to treat asthma symptoms in infants and toddlers are often given in a tasty liquid form, by using a nebulizer with a facemask, or by using an inhaler with a spacer and facemask. A nebulizer (sometimes referred to as a “breathing machine”) is a small machine that uses compressed air to create a medicated mist for the baby to inhale. Nebulizer treatments take about 10 minutes and are usually given several times each day until symptoms decrease. Nebulized medications are given to infants and young children using a facemask. Although some small children are initially apprehensive, with parental reassurance, the majority of children rapidly become accustomed to this form of medication delivery. Blowing the medication near the child’s face without using a facemask is not recommended because so little medication is received. The particle size of the medication is very small and is affected by side stream air resulting in very little actually being inhaled by the infant or small child.

Some toddlers and preschoolers are able to use an inhaler containing asthma medication with a spacer and mask attachment. A spacer is a small tube or chamber that holds the medication released by the inhaler fitted into it. The inhaler/spacer device allows children to breathe in the medication at their own speed. Use of spacers allows for greater variety in the medications that can be prescribed.

Various types of medications are used to treat asthma. “Quick relief” medications such as albuterol help open airways immediately to make breathing easier. “Long-term control” medications such as inhaled steroids help reduce or even eliminate asthma symptoms on an ongoing basis. Most people with asthma, including very young children, use a combination of medications, depending on the severity and frequency of symptoms. You will want to develop an asthma management plan with your child’s physician that outlines what treatments should be used when asthma symptoms change or increase.

What can be done to reduce asthma symptoms in very young children?

If your child has allergies, you can reduce asthma symptoms by controlling allergy triggers in your child’s environment. Concentrate your efforts particularly in the bedroom, and of course, in other areas where your child lives or is active. Here are some guidelines on things you can do:

• Cover the pillows, mattress, and box springs in allergen- proof casings. These coverings are available at many retail stores that sell bedding and also from allergy supply companies.

• Don’t allow pets in the bedroom. Don’t allow pets in the house at all if allergies are severe.

• Use air purifiers with a HEPA filter (only for animal dander sensitive children if there is an animal in the house).

• For all children: Do not allow smoking in the house. Even if someone smokes in the basement of a multi- storied home, the smoke filters through the vents to all parts of the house.

If there is a history of allergies in your family, or if you think your baby may have allergies, slowly introduce new foods into his/her diet so that you can monitor responses. Be especially careful of the foods commonly known to cause an allergic response in many people. These foods include:

There is some evidence that breast-feeding helps prevent children from developing eczema and food allergies in the first years of life, but does not reduce asthma.

Can a child outgrow asthma?

Yes and no. As children’s airways mature, they are better able to handle airway inflammation and irritants. Their asthma symptoms may notably decrease, and it’s not uncommon for asthma to disappear entirely by the time they enter school. This is particularly true for those infants who wheezed only with viral infections and do not have any allergies or allergic persons in their family.

Fast facts . . . Approximately 50% of children with asthma “outgrow” their asthma once they reach or pass through adolescence, although it may return when they are adults.

It’s important to keep in mind that once someone has developed sensitive airways, their respiratory tract remains sensitive to asthma triggers for life. In fact, people who had asthma as young children generally find their asthma symptoms vary throughout their adult years. About half of those children whose symptoms disappeared during their teens have their asthma symptoms reappear in varying degrees when they reach their late thirties or early forties.

There is no way to predict which children may experience greatly reduced symptoms as they get older or whose “outgrown” asthma may reappear in later adulthood; however, generally they have milder asthma in childhood. New triggers may cause symptoms to appear at any time in people with a history of asthma.

Keep in mind . . . If your child has asthma, keep “quick relief” medications on hand and up-to-date — even if symptoms are rare.

How can parents successfully manage asthma in young children?

When a very young child has a chronic illness, parents can feel stretched to their limits as they try to manage. Consider these tips for coping:

• Establish an asthma care management plan with your child’s physician. Make sure the plan gives you guidelines to follow if asthma symptoms get worse. Be clear about when your child’s symptoms require emergency care.

• Follow your child’s asthma care plan every day! Don’t alter from the plan unless you discuss changes with the physician. Review the plan with your childcare provider and provide instructions to all babysitters or other short- term childcare providers as well.

• Teach toddlers and preschoolers to tell you when they aren’t feeling well.

• Work out an emergency plan of action to follow if your child has a serious asthma episode. What hospital will you use? Be sure your pediatrician uses this hospital and it is in your health care plan. Who will take care of your other children? How does your medical coverage provide for emergency care? If someone else is caring for your child, how can you be contacted at all times? Who makes the decision to seek emergency care?

Above all, don’t let your child’s asthma become the focus of your relationship! If you use good health care practice to manage your young child’s asthma, you’ll be able to think less about asthma and enjoy your child more.

Who should treat asthma in a very young child?

Many babies, toddlers, and preschoolers are treated for asthma by their pediatrician; however, if their asthma symptoms are not under control within three to six months, or if symptoms are severe and persistent, or if the asthma episodes require emergency treatment, it may be time to see an asthma specialist. Allergists/Immunologists or pulmonologists (who specialize in the treatment of lung diseases) are specialists who treat asthma. Some allergists and pulmonologists specialize in pediatric medicine. Those who have completed training in those specialties are usually called board-certified or board-eligible.

Does health insurance cover asthma treatment?

Most health insurance plans provide some level of coverage for asthma patients. Check with your insurance carrier for details. Some things you may want to find out might include:

• Do you need a referral to an asthma care specialist from your pediatrician?

• Does the insurance carrier offer any patient education or specialized services related to asthma?

• What medications are not covered by your plan? (There can sometimes be a delay in approving newly released medications. Your physician may know about them, but your insurance may not cover them yet.)

The information provided in this fact sheet should not be a substitute for seeking responsible, professional medical care.

Reprinted with permission from “Asthma and Allergy Answers,” the patient education library developed by the Asthma and Allergy Foundation of America.

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